Safety Lesson learned: Material Release
Location of Incident: Chocolate Bayou, USA
Brief Account of Incident
During a cycle-ending turn around of 2003, a tie-in was made on the Olefins 1 flare header to enable a hydrogen line to be tied in during the 2005 DCP outage. When this line was placed in service after being tied in, the fitting (4” weld-o-let on 8” header) separated from the flare header, leaving an open hole in the header. Analysis of the failure indicated that fatigue failure was the reason the pipe failed. Investigation determined that the line had not been supported for vibration, only for weight.
Potential Outcome
Because this incident left a hole in the flare header as well as an open-ended hydrogen line, the potential outcome was fire.
What Went Wrong
The hydrogen piping that was tied in to the flare header during the 2005 DCP outage was not braced properly to provide adequate protection from fatigue failure of the weld area.
Immediate Causes
Routine activity without thought – Since the tie-in was routine, the designers did not think to analyze for vibration.
System Causes
- Inadequate technical design
- Inadequate assessment of potential failure
- Inadequate standards or specifications
What Went Well
Operator action and the Emergency Response.
Safety Lesson Learned
1. Add a checklist to the piping portion of the specifications dealing with flow-induced vibration.
2. Review the results of the investigation with the engineering departments.
3. Add the review of this incident to the Lessons Learned document for the DCP outage.
4. Review the Hot Tap procedure in the Process Safety Committee.
5. Survey all tie-ins to the flare at Olefins 1 and Olefins 2 to identify other potential issues.
6. Correct any deficiencies found during the audits.
Saturday, October 13, 2007
Electrical Failure
Safety Lesson Learned: Electrical Failure
Location of Incident: Coryton Refinery, UK
Brief Account of Incident
On 15th September at 08:45hrs local time, a fault developed on the external electrical distribution network that ultimately resulted in all Refinery Units apart from the crude unit and the Boiler House shutting down. The Refinery HV protection system sensed the fault and disconnected the Refinery from the external grid. This resulted in the automatic operation of the Refinery power load shedding system. Prior to the incident the refinery was operating normally.
As a result of the initial disturbance some electrical drives tripped, but either re-accelerated or auto-started. However, on the Continuous Catalytic Reformer (CCR) the Waste Heat Boiler Feed Water Pump (BFW) did not auto-start, resulting in a controlled shutdown of the CCR Unit. The CCR is the only hydrogen producing unit for the Refinery and the loss of a hydrogen supply resulted in a domino shutdown of other hydrogen dependent units.
At approx. 08:55hrs, critical control equipment on the Cracking Complex control console in the Central Control Building (CCB) started to fail due to a fluctuating supply voltage. In response to the lack of unit displays and with the knowledge that the majority of Refinery units were shutting down, the decision was made to shutdown the Cracking Complex whilst control was still available.
Outcome
There were no injuries or any significant environmental emissions during the Refinery shutdown. The lost opportunity cost of the shutdown has been estimated at $10.5MM.
Critical Factors
1. Incorrect co-ordination between the external power supply network and Refinery network protection systems.
2. Failure of the CCR BFW pump-motor drive to auto-start.
3. Voltage fluctuations on the Uninterruptible Power Supply (UPS) system distribution network supplying the CCB.
System Causes
1. Inadequate technical design, input obsolote – Refinery and the external power supply protection system settings are not properly coordinated.
2. Insufficient knowldege transfer – there was a lack of understanding around the full functionality of the auto-start facility when only the duty pump/motor was available.
3. Inadequate evaluation and/or documentation of change – the wiring mode were not adequately evaluated and technical query was not issued.
What Went Wrong
- Poor operation/reliability of Production radio communications system.
- Delays in start-up due to piping failures in Product Movement Area.
What Went Well
- there were no injuries or significant environmental incidents during the Refinery shutdown.
- the Refinery power load shedding system (SCADA) operated as per design.
- the Major Incident Team effectively managed the incident with tremendous team support from all Refinery Department.
- Boiler House facilities including steam and power generation remained on-line.
- All units were made safe and abnormal start-up procedures instigated and followed.
Safety Lesson Learned
1. Need to periodically conduct System Studies and Interconnection Studies to ensure correct settings on electrical protection systems.
2. Need to understand the full functionality of pump auto-start facilities. Realize they can be different in design and functionality.
3. Equipment installations especially on UPS and Safety Critical systems must be thoroughly tested before commissioning.
Location of Incident: Coryton Refinery, UK
Brief Account of Incident
On 15th September at 08:45hrs local time, a fault developed on the external electrical distribution network that ultimately resulted in all Refinery Units apart from the crude unit and the Boiler House shutting down. The Refinery HV protection system sensed the fault and disconnected the Refinery from the external grid. This resulted in the automatic operation of the Refinery power load shedding system. Prior to the incident the refinery was operating normally.
As a result of the initial disturbance some electrical drives tripped, but either re-accelerated or auto-started. However, on the Continuous Catalytic Reformer (CCR) the Waste Heat Boiler Feed Water Pump (BFW) did not auto-start, resulting in a controlled shutdown of the CCR Unit. The CCR is the only hydrogen producing unit for the Refinery and the loss of a hydrogen supply resulted in a domino shutdown of other hydrogen dependent units.
At approx. 08:55hrs, critical control equipment on the Cracking Complex control console in the Central Control Building (CCB) started to fail due to a fluctuating supply voltage. In response to the lack of unit displays and with the knowledge that the majority of Refinery units were shutting down, the decision was made to shutdown the Cracking Complex whilst control was still available.
Outcome
There were no injuries or any significant environmental emissions during the Refinery shutdown. The lost opportunity cost of the shutdown has been estimated at $10.5MM.
Critical Factors
1. Incorrect co-ordination between the external power supply network and Refinery network protection systems.
2. Failure of the CCR BFW pump-motor drive to auto-start.
3. Voltage fluctuations on the Uninterruptible Power Supply (UPS) system distribution network supplying the CCB.
System Causes
1. Inadequate technical design, input obsolote – Refinery and the external power supply protection system settings are not properly coordinated.
2. Insufficient knowldege transfer – there was a lack of understanding around the full functionality of the auto-start facility when only the duty pump/motor was available.
3. Inadequate evaluation and/or documentation of change – the wiring mode were not adequately evaluated and technical query was not issued.
What Went Wrong
- Poor operation/reliability of Production radio communications system.
- Delays in start-up due to piping failures in Product Movement Area.
What Went Well
- there were no injuries or significant environmental incidents during the Refinery shutdown.
- the Refinery power load shedding system (SCADA) operated as per design.
- the Major Incident Team effectively managed the incident with tremendous team support from all Refinery Department.
- Boiler House facilities including steam and power generation remained on-line.
- All units were made safe and abnormal start-up procedures instigated and followed.
Safety Lesson Learned
1. Need to periodically conduct System Studies and Interconnection Studies to ensure correct settings on electrical protection systems.
2. Need to understand the full functionality of pump auto-start facilities. Realize they can be different in design and functionality.
3. Equipment installations especially on UPS and Safety Critical systems must be thoroughly tested before commissioning.
Friday, October 12, 2007
Left Eye Injury From Blending Repair Weld
Safety Lesson Learned: Left Eye Injury From Blending Repair Weld
Location of Incident: Dragline 28
Brief Account of Incident
At approximately 1300HRS on the 14th Jan 2003, a boilermaker (not a Fluor project) suffered a serious eye injury from a fragment of shattered grinding disc penetrating the inner lens of his welding helmet and subsequently his eye. The employee was grinding a repair weld on the lower stabiliser link of the RHS propel of the dragline with a 5 inch electric grinder when it is believed
that the tool jammed. It then appears that upon releasing the grinder, the disc shattered and penetrated his eye protection.
The injured person was transported and treated by an eye specialist upon arrival. He has suffered a permanent loss of vision in his left eye.
Contibuting Factors
Pending outcomes of the final investigation, preliminary findings indicate that the below factors may have contributed to the injury:
- Restricted work environment necessitating close proximity to the area being ground.
- Jamming/stalling of the grinder and subsequent failure of the disc wheel.
- The inner lens of the welding helmet, which should be impact resistant, may inadvertently have been replaced with an anti-splatter cover lens, offering little impact resistance.
As the inner lens of welding helmets are interchangeable, it is possible to replace the inner polycarbonate lens with an anti-splatter cover lens, the latter offering minimal impact resistance
Improvement Measurement
The following preventive actions are being adressed:
- Check of welding helmets on site to ensure the correct lens plates are installed in the correct position.
- Discussion of the incident possible causes and interim preventative measures with mine site personnel.
- Interim measure of mandating a face shield and safety glasses be worn whilst performing grinding as opposed to welding helmets
- Further investigation into equipment and tooling capability / protection levels
Location of Incident: Dragline 28
Brief Account of Incident
At approximately 1300HRS on the 14th Jan 2003, a boilermaker (not a Fluor project) suffered a serious eye injury from a fragment of shattered grinding disc penetrating the inner lens of his welding helmet and subsequently his eye. The employee was grinding a repair weld on the lower stabiliser link of the RHS propel of the dragline with a 5 inch electric grinder when it is believed
that the tool jammed. It then appears that upon releasing the grinder, the disc shattered and penetrated his eye protection.
The injured person was transported and treated by an eye specialist upon arrival. He has suffered a permanent loss of vision in his left eye.
Contibuting Factors
Pending outcomes of the final investigation, preliminary findings indicate that the below factors may have contributed to the injury:
- Restricted work environment necessitating close proximity to the area being ground.
- Jamming/stalling of the grinder and subsequent failure of the disc wheel.
- The inner lens of the welding helmet, which should be impact resistant, may inadvertently have been replaced with an anti-splatter cover lens, offering little impact resistance.
As the inner lens of welding helmets are interchangeable, it is possible to replace the inner polycarbonate lens with an anti-splatter cover lens, the latter offering minimal impact resistance
Improvement Measurement
The following preventive actions are being adressed:
- Check of welding helmets on site to ensure the correct lens plates are installed in the correct position.
- Discussion of the incident possible causes and interim preventative measures with mine site personnel.
- Interim measure of mandating a face shield and safety glasses be worn whilst performing grinding as opposed to welding helmets
- Further investigation into equipment and tooling capability / protection levels
Acetylene Cylinder Fire
Safety Lesson Learned: Acetylene Cylinder Fire
Location of Incident: Kuantan, Pahang
Brief Account of Incident
A contractor was performing gas cutting of handrail modification work on the platform above a sacrificial heater. A flashback occurred of the acetylene supply, back to the cylinder. The firewatcher under the working area noticed the acetylene cylinder had caught a fire. He put out the fire by extinguisher at once with the help of one operator on site. After the fire was extinguished, they found the drain plug of the cylinder was leaking, so they took it to a safe place to let it vent to atmosphere.
An investigation team was organized at once. Later analysis found the probably cause was the acetylene hose at the connection with the flammable arrester was cracked. Simultaneously the drain plug was leaking, which was ignited by flashback.
Potential Outcome
- Cylinder gas explosion
- injury and/or fatality
What Went Well
- The flashback arrester was used and the cylinder explosion was avoided.
- The extinguiser was well prepared and both firewatcher and operator reacted rapidly to deal with the emergency situation
What Went wrong
- The worker did not check gas cylinder for leakage prior to the work commencement.
- The gas hose was aging and has no securing clip.
Immediate Causes
- Following Procedure: The worker didn’t check the tools and equipment properly.
- Use of Tools or Equipment: The hose connection was cracked and without securing clip.
- Inattention/Lack of Awareness: The workers were unaware of leakage and flashback.
- Tools, Equipment and Vehicle: The cylinder had a drain plug leakage and the hose was defective
Location of Incident: Kuantan, Pahang
Brief Account of Incident
A contractor was performing gas cutting of handrail modification work on the platform above a sacrificial heater. A flashback occurred of the acetylene supply, back to the cylinder. The firewatcher under the working area noticed the acetylene cylinder had caught a fire. He put out the fire by extinguisher at once with the help of one operator on site. After the fire was extinguished, they found the drain plug of the cylinder was leaking, so they took it to a safe place to let it vent to atmosphere.
An investigation team was organized at once. Later analysis found the probably cause was the acetylene hose at the connection with the flammable arrester was cracked. Simultaneously the drain plug was leaking, which was ignited by flashback.
Potential Outcome
- Cylinder gas explosion
- injury and/or fatality
What Went Well
- The flashback arrester was used and the cylinder explosion was avoided.
- The extinguiser was well prepared and both firewatcher and operator reacted rapidly to deal with the emergency situation
What Went wrong
- The worker did not check gas cylinder for leakage prior to the work commencement.
- The gas hose was aging and has no securing clip.
Immediate Causes
- Following Procedure: The worker didn’t check the tools and equipment properly.
- Use of Tools or Equipment: The hose connection was cracked and without securing clip.
- Inattention/Lack of Awareness: The workers were unaware of leakage and flashback.
- Tools, Equipment and Vehicle: The cylinder had a drain plug leakage and the hose was defective
Monday, October 1, 2007
Failure of Fire Hose
Safety Lesson Learned: Failure of Fire Hose
Location of Incident: Kerteh, Malaysia
Brief Account of Incident
At approximately 23:45hrs on Sunday 24th February 2003 PEMSB Operation ‘A’ shift started their monthly fire drill. The drill was basically a practice of handling a fire hose. They completed setting up the hoses to the breach and hydrant then started to line up the firewater. After about 5 minutes the Team Leader realized that the water pressure was not very high. He therefore proceeded to the hydrant to increase the opening of the firewater valve. On his way back towards the breach the 2½” hose started snaking for about 10 secs before it separated from the coupling. The hose swung around a radius of approx 10ft for about 15 secs before the firewater isolated by the Team Leader. He was about 5 to 6 meters away from the breach when the hose burst. Upon checking it was found that only the hose was separated while the coupling was still intact to the breach. The binding of the hose was found 10 meters away from the breach. The drill was immediately stopped.
Potential Outcome
Injury to personnel from flying hose or binding
Critical Factors
· Failure of the fire water hose binding
· No checking of the condition of the firewater hose prior to use.
Location of Incident: Kerteh, Malaysia
Brief Account of Incident
At approximately 23:45hrs on Sunday 24th February 2003 PEMSB Operation ‘A’ shift started their monthly fire drill. The drill was basically a practice of handling a fire hose. They completed setting up the hoses to the breach and hydrant then started to line up the firewater. After about 5 minutes the Team Leader realized that the water pressure was not very high. He therefore proceeded to the hydrant to increase the opening of the firewater valve. On his way back towards the breach the 2½” hose started snaking for about 10 secs before it separated from the coupling. The hose swung around a radius of approx 10ft for about 15 secs before the firewater isolated by the Team Leader. He was about 5 to 6 meters away from the breach when the hose burst. Upon checking it was found that only the hose was separated while the coupling was still intact to the breach. The binding of the hose was found 10 meters away from the breach. The drill was immediately stopped.
Potential Outcome
Injury to personnel from flying hose or binding
Critical Factors
· Failure of the fire water hose binding
· No checking of the condition of the firewater hose prior to use.
PTA Forklift Incident
Safety Lesson Learned: PTA Forklift Incident
Location: Kuantan, Malaysia
Brief Account of Incident
After carrying out re-bagging of a damaged PTA bag (1.1 tone) using two forklift trucks, one of the forklift trucks driver got out of the cab to remove the empty bag, as he was standing in front of his forklift and leaning forward to remove the empty bag from the forks of the truck, the second forklift truck (which was now transporting the full bag) made contact with him as the truck driving forward and turning to get out of the gate. This contact knocked the person on to the stationary forklift. The Injured person was sent to local hospital by the emergency response team and given a comprehensive medical check. He was discharged later that morning, suffering only localized bruising.
Possible Immediate Cases
1. Improper use of equipment
The re-bagging operation should use the fixed hoist rather than using two Forklifts.
2. Improper decision-making or lack of judgment
The Injured Person stand at a very dangerous position but he did not pay much attention on it.
3. Routine activity without thought
The Forklift Driver just reverse the Forklift and drive forward, turn without noticing that the person is just in front of his Forklift.
4. Congestion or restricted motion
The Packaging area is too small and there is another Forklift parking there to limit the space for the Forklift movement
Location: Kuantan, Malaysia
Brief Account of Incident
After carrying out re-bagging of a damaged PTA bag (1.1 tone) using two forklift trucks, one of the forklift trucks driver got out of the cab to remove the empty bag, as he was standing in front of his forklift and leaning forward to remove the empty bag from the forks of the truck, the second forklift truck (which was now transporting the full bag) made contact with him as the truck driving forward and turning to get out of the gate. This contact knocked the person on to the stationary forklift. The Injured person was sent to local hospital by the emergency response team and given a comprehensive medical check. He was discharged later that morning, suffering only localized bruising.
Possible Immediate Cases
1. Improper use of equipment
The re-bagging operation should use the fixed hoist rather than using two Forklifts.
2. Improper decision-making or lack of judgment
The Injured Person stand at a very dangerous position but he did not pay much attention on it.
3. Routine activity without thought
The Forklift Driver just reverse the Forklift and drive forward, turn without noticing that the person is just in front of his Forklift.
4. Congestion or restricted motion
The Packaging area is too small and there is another Forklift parking there to limit the space for the Forklift movement
Fire Explosion In Refinery
Safety Lesson Learned: Fire Explosion In Refinery
Location: Thai Oil
Brief Account of Incident
Basically one of their gasoline tanks overflowed. A security guard detected a strong smell and notified shift control who sent two operators to investigate. They don’t walk but they drive. Say no more, the bang was so big and shook the apartment building in Pattaya about 20kms away.
The fire spread from one tank to 4 others before it was contained and eventually put out by allowing the fuel to completely burn out, over 100,000 litres. There was 8 fatalities and 13 hospitalized with serious injuries. Fortunately it had occurred during silence hours and save over 100 people as admin building, maintenance workshop store and medical center were either completely gutted or severely damaged by the blast.
Safety Lesson Learned
1. If you see a release of flammable material: Turn in the plant alarm, identify the wind direction.
2. If you hear any plant alarm: Stop work, extinguish cigarettes, if you’re in a vehicle immediately stop and turn off the engine.
3. If the plant alarm for toxic gas: Assembly point is in control room.
4. There should a rules for taking vehicles anywhere inside a plant. For such situation confine all vehicles to the main roads and designated parking areas.
5. Never forget that we handle very dangerous chemicals. Be careful and follow the HSE procedures, operating procedures and maintenance procedures so horrible accidents such as this can be avoided.
Location: Thai Oil
Brief Account of Incident
Basically one of their gasoline tanks overflowed. A security guard detected a strong smell and notified shift control who sent two operators to investigate. They don’t walk but they drive. Say no more, the bang was so big and shook the apartment building in Pattaya about 20kms away.
The fire spread from one tank to 4 others before it was contained and eventually put out by allowing the fuel to completely burn out, over 100,000 litres. There was 8 fatalities and 13 hospitalized with serious injuries. Fortunately it had occurred during silence hours and save over 100 people as admin building, maintenance workshop store and medical center were either completely gutted or severely damaged by the blast.
Safety Lesson Learned
1. If you see a release of flammable material: Turn in the plant alarm, identify the wind direction.
2. If you hear any plant alarm: Stop work, extinguish cigarettes, if you’re in a vehicle immediately stop and turn off the engine.
3. If the plant alarm for toxic gas: Assembly point is in control room.
4. There should a rules for taking vehicles anywhere inside a plant. For such situation confine all vehicles to the main roads and designated parking areas.
5. Never forget that we handle very dangerous chemicals. Be careful and follow the HSE procedures, operating procedures and maintenance procedures so horrible accidents such as this can be avoided.
Subscribe to:
Posts (Atom)